Bronchial Asthma - Early Indicators for Diagnosis and Its Management in Indian Practice Settings

Bronchial Asthma-Indian Perspective

Asthma is a chronic inflammatory airway disease associated with airway remodeling; augmenting its smooth muscle mass, and consequentially leading to fibrosis of airway linings (1). It is estimated that about 38 million people are living with asthma in India (2). The burden is higher among those living in households using solid fuels like firewood and kerosene (3). Asthma has reported a significant impact on the emotional well-being of the Indian pediatric population. Such factors increase the burden of obstructive pulmonary airway illnesses and raise the need for effective maintenance therapies. Despite an ever-increasing prevalence of this condition across all age groups, asthma continues to remain poorly managed in India. The majority of Indian patients remain undiagnosed or wrongly diagnosed in general clinical practice. The diagnosed patients with asthma remain sub-optimally treated. The clinical predictors guiding the evaluation of high-risk population and early diagnosis of bronchial asthma is aimed to be reviewed. (4)

Predicting Early Signs of Asthma: Eyes will See What the Mind Knows!!

Because there is no gold standard test for asthma and because it is recognized as a disease with a wide range of etiologies, phenotypes, and clinical manifestations, clinical diagnosis of asthma, in the early stages, is largely based on symptoms; and management is based on prompt identification of the "treatable traits" to allow for targeted and personalized therapy. (5)

Research highlights that the varied asthma predictors include, but are not limited to, reversible airflow restriction, airway inflammation, hyper-responsiveness, bronchial obstruction airway eosinophilia, and symptoms of recurrent wheezing, coupled with dyspnoea and cough. (5)

In a recent observational cohort published by Paula H et al, in 2022, it was demonstrated that over half of participants hospitalized for viral wheezing episodes in early childhood had asthma in young adulthood. An asthma diagnosis at any age during childhood, as well as eosinophilia in early childhood, were independent significant predictive risk factors for asthma. (6)

Early life determinants for Bronchial Asthma(BA): A positive family history, passive smoking exposure during pregnancy, prematurity, including pulmonary infections, respiratory distress syndrome (RDS), early viral respiratory infections, such as respiratory syncytial virus bronchiolitis), male gender, and atopic constitution are cited as some of the early life determinants associated with bronchial asthma. The major risk factor for persistent BA is an underlying allergic constitution. Therefore, early symptoms, markers of allergy, like 'Allergic March' (allergies begin early in life, first expressing themselves as eczema, progressing to later developing into food allergies, allergic rhinitis, and asthma), and positive family history of allergy could be considered as important risk factors for the development of BA. (4)

Clinical Markers: Recognizing the signs and symptoms of asthma is an important part of managing asthma. (7)

Knowing when early warning signs or mild symptoms are occurring is of great value as it helps to facilitate early intervention and better long-term outcomes. Early warning signs often precede an asthma episode. (7)

The manifestation of these signs may be highly varied. Persistent cough, wheezing, chest tightness, and/or shortness of breath should be suspected as asthma. Variable symptoms that intensify at night, occur when exposed to triggers such as allergens or irritants, and respond to adequate asthma medication are strongly indicative of asthma. (8)

In addition, there may be signs like odd feeling in the chest, watery eyes, dry mouth, etc listed in certain scientific literature It may be prudent for the treating clinician to co-relate these prodromal signs and symptoms with history and other relevant clinical facets in every patient.(7)

Management of Bronchial Asthma: Practice Pointers

The initial asthma management and recommended treatment options for adults &adolescents may be based upon presenting clinical symptoms. An overview from the Global Strategy for Asthma Management and Prevention, a Global Initiative for Asthma (GINA) updated 2022 recommendations are summarized below (9):

• For infrequent asthma symptoms, i.e. < 2 times a month and no risk factors for exacerbations, low dose ICS (inhaled corticosteroids)- formoterol may be considered. Other options include ICS whenever short-acting beta-2 agonists (SABA) are taken, in combination or with separate inhalers.
• For treatment of asthma symptoms, and need for reliever >2 times a month, as-needed low dose ICS-formoterol, or low dose ICS with as-needed SABA, may be considered.
• When asthma symptoms are troublesome on most days or waking due to asthma more than once, especially if any risk factors exist, low-dose inhaled corticosteroids – as maintenance and reliever therapy are to be focused on. Alternative therapy includes low-dose ICS -LABA or as-needed SABA.
• In cases where initial asthma presentation is with severely uncontrolled asthma, or with an acute exacerbation, initiate medium-dose ICS (as reliever and maintenance therapy), or medium-to- high dose ICS-LABA, with as-needed SABA. A short course of oral corticosteroids may also be needed in this patient population. (10)

Salbutamol: Standing the Test of Time in Bronchial Asthma Management

Salbutamol in Bronchial Asthma – Recommendations from Indian Medical Association: The Indian Medical Associations' recommendations on the management of bronchial asthma in primary care settings have been cited regarding the therapeutic utility of salbutamol in the management of bronchial asthma. It is recommended that non-severe exacerbations of bronchial asthma could be initially treated with inhaled salbutamol; 4-6 puffs of 100 μg are administered every 30 minutes. (4)

Place of Salbutamol in Bronchial Asthma Management: Indian Guidelines: The Indian Chest Society (ICS) and the National College of Chest Physicians (NCCP) collaboratively published the Joint ICS/NCCP recommendations for the management of bronchial asthma; refer to the following statements in relevance to the clinical opportunity for use of Salbutamol:

• SABAs like salbutamol is one of the recommended treatment options for rescue medication in stable asthma (11).
• Rapid‑acting inhaled beta‑2 agonists (salbutamol) are the bronchodilators of choice for managing asthma (11).
• In non‑severe exacerbations of bronchial asthma, patients should be initially managed with inhaled Short-acting beta-agonists (SABA). This could include 4‑6 puffs of 100 µg salbutamol every 30 minutes.

Bronchial asthma in Indian practice settings will continue to remain a significant healthcare burden (2) due to persistent and difficult to modify environmental and other extrinsic risk factors. (6) Salbutamol may be considered in the correct treatment of mild to moderate asthma exacerbations among adults, adolescents, and children aged 6-11 years of age. (12) Inhaled salbutamol is extensively utilized due to its rapid onset of action and could be considered of clinical value in the treatment or prevention of bronchospasm and prevention of exercise-induced bronchospasm in adults and pediatric patients with reversible obstructive airway disease. (13)

References:

1. Boulet LP. Pocket Guide for Asthma Management and Prevention.; 2019. https://ginasthma.org/wp-content/uploads/2019/04/GINA-2019-main-Pocket-Guide-wms.pdf

2. Salvi SS. The burden of chronic respiratory diseases and their heterogeneity across the states of India : the Global Burden of Disease Study 1990 – 2016. Lancet 2018; 6:e478–89. doi:10.1016/S2214-109X(18)30409-1

3. Faizan, M. A., & Thakur, R. (2019). Association Between Solid Cooking Fuels and Respiratory Disease Across Socio-Demographic Groups in India. Journal of health & pollution, 9(23), 190911. https://doi.org/10.5696/2156-9614-9.23.190911

4. Van Bever HP. Determinants in early life for asthma development. Allergy Asthma Clin Immunol. 2009 Nov 9;5(1):6. doi: 10.1186/1710-1492-5-6. PMID: 20016777; PMCID: PMC2794849.

5. Saglani, S., & Menzie-Gow, A. N. (2019). Approaches to Asthma Diagnosis in Children and Adults. Frontiers in pediatrics, 7, 148. https://doi.org/10.3389/fped.2019.00148

6. Heikkilä P, Korppi M, Ruotsalainen M, Backman K. Viral wheezing in early childhood as a risk factor for asthma in young adulthood: A prospective long-term cohort study. Health Sci Rep. 2022 Mar 7;5(2):e538. doi: 10.1002/hsr2.538. PMID: 35284656; PMCID: PMC8900980.

7. National Jewish Facts, Medfacts Educational Health Series 2009,Pg 1-3

8. Quirt, J., Hildebrand, K. J., Mazza, J., Noya, F., & Kim, H. (2018). Asthma. Allergy, asthma, and clinical immunology : official journal of the Canadian Society of Allergy and Clinical Immunology, 14(Suppl 2), 50. https://doi.org/10.1186/s13223-018-0279-0

9. https://ginasthma.org/gina-reports/

10. Global Initiative for Asthma, Global Strategy for Asthma Management and Prevention, 2020. Available from https://ginasthma.org/

11. Agarwal R, Dhooria S, Aggarwal AN, Maturu VN, Sehgal IS, Muthu V, et al. Guidelines for diagnosis and management of bronchial asthma: Joint ICS/NCCP (I) recommendations. Lung India 2015;32:3-42.

12. Global strategy for Asthma Management and Prevention, Updated 2019, Pages 1-199

13. Innovator Prescribing Information, Albuterol Sulfate, , VENTOLIN HFA, last updated August 2021